foundation of nursing practice questions

foundation of nursing practice questions Related

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A nurse is providing care for a patient who has recently been admitted to the postsurgical unit from PACU following a transuretheral resection of the prostate. The nurse is aware of the nursing diagnosis of Risk for Imbalanced Fluid Volume. In order to assess for this risk, the nurse should prioritize what action?

  • A. Closely monitoring the input and output of the bladder irrigation system
  • B. Administering parenteral nutrition and fluids as ordered
  • C. Monitoring the patients level of consciousness and skin turgor
  • D. Scanning the patients bladder for retention every 2 hours
Correct Answer: A

Rationale: The nurse should prioritize closely monitoring the input and output of the bladder irrigation system to assess for the risk of imbalanced fluid volume in a patient following a transuretheral resection of the prostate. Bladder irrigation is a common postoperative procedure used to prevent blood clots and help with healing. Monitoring the input and output of the bladder irrigation system is crucial in assessing the patient's fluid balance. Changes in the output may indicate bleeding or retention, which can lead to imbalanced fluid volume. By closely monitoring the bladder irrigation system, the nurse can promptly identify any issues and intervene accordingly to prevent further complications. Monitoring the patient's level of consciousness, skin turgor, and scanning for bladder retention are important assessments, but for this specific situation, monitoring the bladder irrigation system is the priority to assess for imbalanced fluid volume.

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A nurse is assessing a patient with an acoustic neuroma who has been recently admitted to an oncology unit. What symptoms is the nurse likely to find during the initial assessment?

  • A. Loss of hearing, tinnitus, and vertigo
  • B. Loss of vision, change in mental status, and hyperthermia
  • C. Loss of hearing, increased sodium retention, and hypertension
  • D. Loss of vision, headache, and tachycardia
Correct Answer: A

Rationale: A nurse assessing a patient with an acoustic neuroma would likely find symptoms such as loss of hearing, tinnitus, and vertigo. Acoustic neuroma, also known as vestibular schwannoma, is a noncancerous tumor that develops on the vestibulocochlear nerve, which carries sound and balance signals from the inner ear to the brain. The most common symptoms of an acoustic neuroma include progressive hearing loss, ringing in the ears (tinnitus), and dizziness or imbalance (vertigo). Therefore, option A is the most appropriate choice for the symptoms that the nurse is likely to find in a patient with an acoustic neuroma.

The nurse is caring for a 52-year-old woman whose aunt and mother died of breast cancer. The patient states, My doctor and I talked about Tamoxifen to help prevent breast cancer. Do you think it will work? What would be the nurses best response?

  • A. Yes, its known to have a slight protective effect.
  • B. Yes, but studies also show an increased risk of osteoporosis.
  • C. You wont need to worry about getting cancer as long as you take Tamoxifen.
  • D. Tamoxifen is known to be a highly effective protective measure.
Correct Answer: A

Rationale: The nurse's best response should be to provide accurate information and manage the patient's expectations realistically. Tamoxifen is known to have a slight protective effect in reducing the risk of developing breast cancer in high-risk individuals like the patient in the scenario. However, it is not a guarantee against developing breast cancer. It is essential for the nurse to convey this information to the patient to ensure that she understands the benefits and limitations of Tamoxifen therapy. Additionally, discussing potential side effects and risks associated with Tamoxifen, such as an increased risk of osteoporosis, is important for the patient to make an informed decision about her health care.

The patient hasH. pylori. Which action shouldthe nurse take?

  • A. Encourage avoidance of wheat and oats.
  • B. Encourage milkshakes as a nutritious snack.
  • C. Encourage completion of antibiotic therapy.
  • D. Encourage nonsteroidal antiinflammatory drugs.
Correct Answer: C

Rationale: The most appropriate action for a patient with H. pylori is to encourage completion of antibiotic therapy. H. pylori is a bacterium that causes peptic ulcers, and treatment involves a combination of antibiotics to eradicate the infection. Antibiotic therapy is crucial in eliminating the bacteria and preventing complications such as recurrent ulcers or stomach cancer. Therefore, the nurse should prioritize ensuring that the patient completes the prescribed course of antibiotics to effectively treat the H. pylori infection.

A nurse is discussing the advantages of a nursingclinical information system. Which advantage should the nurse describe?

  • A. Varied clinical databases
  • B. Reduced errors of omission
  • C. Increased hospital costs
  • D. More time to read charts
Correct Answer: B

Rationale: One of the key advantages associated with a nursing clinical information system is the reduction of errors of omission. By using an electronic system that prompts for required data entry and ensures completeness of documentation, nurses are less likely to miss important information, leading to improved patient care and safety. This advantage helps in promoting efficient communication among healthcare providers and contributes to better decision-making processes.

A 35-year-old man is seen in the clinic because he is experiencing recurring episodes of urinary frequency, dysuria, and fever. The nurse should recognize the possibility of what health problem?

  • A. Chronic bacterial prostatitis
  • B. Orchitis
  • C. Benign prostatic hyperplasia
  • D. Urolithiasis
Correct Answer: A

Rationale: The symptoms of urinary frequency, dysuria, and fever in a 35-year-old man are indicative of chronic bacterial prostatitis. Prostatitis is inflammation of the prostate gland, which can be caused by bacterial infection. Chronic bacterial prostatitis is characterized by recurrent episodes of infection leading to symptoms like urinary urgency, frequency, dysuria, and sometimes fever. It is important to identify and treat chronic bacterial prostatitis promptly to prevent complications and improve quality of life for the patient.

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